Asymmetry in CT Scan Measures of Thigh Muscle 2 Months After Hip Fracture: The Baltimore Hip Studies.

BACKGROUND: Hip fracture is an important problem for older adults with significant functional consequences. After hip fracture, reduced muscle loading can result in muscle atrophy. METHODS: We compared thigh muscle characteristics in the fractured leg to those in the nonfractured leg in participants from the Baltimore Hip Studies 7th cohort using computed tomography scan imaging. RESULTS: At 2 months postfracture, a single 10mm axial computed tomography scan was obtained at the midthigh level in 43 participants (23 men, 20 women) with a mean age of 79.9 years (range: 65-96 years), and thigh muscle cross-sectional area, cross-sectional area of intermuscular adipose tissue, and mean radiologic attenuation were measured. Total thigh muscle cross-sectional area was less on the side of the fracture by 9.46cm(2) (95% CI: 5.97cm(2), 12.95cm(2)) while the cross-sectional area of intermuscular adipose tissue was greater by 2.97cm(2) (95% CI: 1.94cm(2), 4.01cm(2)) on the fractured side. Mean muscle attenuation was lower on the side of the fracture by 3.66 Hounsfield Units (95% CI: 2.98 Hounsfield Units, 4.34 Hounsfield Units). CONCLUSIONS: The observed asymmetry is consistent with the effect of disuse and inflammation in the affected limb along with training effects in the unaffected limb due to the favoring of this leg with ambulation during the postfracture period.

Asymmetry in CT Scan Measures of Thigh Muscle 2 Months After Hip Fracture: The Baltimore Hip Studies.

BACKGROUND: Hip fracture is an important problem for older adults with significant functional consequences. After hip fracture, reduced muscle loading can result in muscle atrophy. METHODS: We compared thigh muscle characteristics in the fractured leg with those in the nonfractured leg in participants from the Baltimore Hip Studies 7th cohort using computed tomography (CT) scan imaging. RESULTS: At 2 months postfracture, a single 10-mm axial CT scan was obtained at the midthigh level in 47 participants (26 men and 21 women) with a mean age of 80.4 years (range 65-96), and thigh muscle cross-sectional area (CSA), CSA of intermuscular adipose tissue (IMAT), as well as mean radiological attenuation were measured. Total thigh muscle CSA was less on the side of the fracture by 9.2 cm(2) (95% CI: 5.9, 12.4 cm(2)), whereas the CSA of IMAT was greater by 2.8 cm(2) (95% CI: 1.9, 3.8 cm(2)) on the fractured side. Mean muscle attenuation was lower on the side of the fracture by 3.61 HU (95% CI: 2.99, 4.24 HU). CONCLUSIONS: The observed asymmetry is consistent with the effect of disuse and inflammation in the affected limb along with training effects in the unaffected limb due to the favoring of this leg with ambulation during the postfracture period.

Body mass index is positively associated with bone mineral density in US older adults.

UNLABELLED: Literature has been conflicting as to whether obesity is protective against osteoporosis. Understanding the relationship is particularly important in light of the increasing prevalence of obesity among older adults. Study results confirm a protective association between obesity and osteoporosis in a recent, nationally representative sample of US older adults. PURPOSE: Currently, the majority of US older adults are either overweight or obese. Evidence regarding the relationship between body composition measures and bone mass is conflicting, possibly because different measures of obesity reflect multiple mechanisms. Additionally, there are important age, gender, and racial differences in a risk of osteoporosis and fat mass composition. The objective of this study was to examine the association between body mass index (BMI) and bone mineral density (BMD) in a recent, nationally representative sample of US older adults as well as to see if this relationship differs by age, sex, and race. METHODS: Data for this study were obtained from the National Health and Nutrition Examination Survey (2005-2008) for adults ages 50 and older (n = 3,296). Linear regression models were used to predict BMD of the femoral neck (measured by dual-energy X-ray absorptiometry (DXA)) as a function of BMI (measured height and weight) and a range of study covariates. RESULTS: Every unit increase in BMI was associated with an increase of 0.0082 g/cm(2) in BMD (p < 0.001). Interaction terms for BMI and age (p = 0.345), BMI and sex (p = 0.413), and BMI and race (p = 0.725) were not statistically significant. CONCLUSIONS: Study results confirm the positive association between BMI and BMD, and this relationship does not differ by age, sex, or race. A 10-unit increase in BMI (e.g., from normal BMI to obese) would result in moving an individual from an osteoporotic BMD level to a normal BMD level. Results demonstrate a protective, cross-sectional association between obesity and osteoporosis in a recent sample of US older adults.

Short-term changes in body composition after surgical repair of hip fracture.

BACKGROUND: the deleterious changes in body composition that occur during the year after hip fracture are associated with increased disability, recurrent fracture, and mortality. While the majority of these unfavourable changes have been shown to occur during the first 2 months after fracture, potential changes in body composition occurring earlier than 2 months post-fracture have not been studied. Accordingly, the aim of this study was to rigorously assess short-term changes in body composition after hip fracture. METHODS: total body mass, lean mass, fat mass and total hip and femoral neck bone mineral density (BMD) were assessed via dual energy X-ray absorptiometry at 3 days, 10 days and 2 months post-fracture among 155 hip fracture patients from the Baltimore Hip Studies. Longitudinal regression analysis using mixed models was conducted to model short-term changes in body composition. RESULTS: no significant changes in body composition were revealed from 3- to 10 days post-fracture. However, significant decreases from 10 days to 2 months post-fracture were noted in the total body mass (-1.95 kg, P < 0.001), lean mass (-1.73 kg, P < 0.001), total hip BMD (-0.00812 g/cm(2), P = 0.04) and femoral neck BMD (-0.015 g/cm(2), P = 0.03). No meaningful changes in fat mass were uncovered. CONCLUSIONS: the adverse changes in body composition during the first 2 months after hip fracture appear to have occurred primarily between 10 days and 2 months post-fracture. More research is needed to determine how these findings might help inform the optimal timing of interventions aimed at improving body composition and related outcomes after hip fracture.

Care-related risk factors for hospital-acquired pressure ulcers in elderly adults with hip fracture.

OBJECTIVES: To identify care-related factors associated with hospital-acquired pressure ulcers (HAPUs). DESIGN: Prospective cohort study. SETTING: Nine hospitals in Baltimore Hip Studies network. PARTICIPANTS: Six hundred fifty-eight individuals aged 65 and older who underwent surgery for hip fracture. MEASUREMENTS: Skin examinations at baseline and on alternating days until hospital discharge. Participants were deemed to have a HAPU if they developed one or more new Stage 2 or higher pressure ulcers (PUs) during the hospital stay. RESULTS: Longer emergency department stays were associated with lower HAPU incidence (>4-6 hours: adjusted incidence rate ratio (aIRR) = 0.68, 95% confidence interval (CI) = 0.48-0.96; >6 hours: aIRR = 0.68, 95% CI = 0.46-0.99, both vs ≤ 4 hours). Participants with 24 hours or longer between admission and surgery had a higher postsurgery HAPU rate than those with less than 24 hours (aIRR = 1.62, 95% CI = 1.24-2.11). Surgery with general anesthesia had a lower postsurgery HAPU rate than surgery with other types of anesthesia (aIRR = 0.66, 95% CI = 0.49-0.88). There was no significant association between HAPU incidence and timing of transport to the hospital, type of transport to the hospital, or surgery duration. CONCLUSION: Most of the factors hypothesized to be associated with higher PU incidence were associated with lower incidence or were not significantly associated, suggesting that HAPU development may not be as sensitive to care-related factors as commonly believed. Rigorous studies of innovative preventive interventions are needed to inform policy and practice.

Inflammatory cytokine levels and depressive symptoms in older women in the year after hip fracture: findings from the Baltimore Hip Studies.

OBJECTIVES: To determine whether interleukin (IL)-6 or soluble tumor necrosis factor alpha receptor 1 (sTNF-αR1) is associated with depressive symptoms in the year after hip fracture. DESIGN: Prospective cohort. SETTING: Three Baltimore-area hospitals. PARTICIPANTS: Community-dwelling women aged 65 and older admitted with a new, nonpathological fracture of the proximal femur (N = 134). MEASUREMENTS: Two, 6, and 12 months after fracture, serum was analyzed for IL-6 and sTNF-αR1, and depressive symptoms were measured using the 15-item Geriatric Depression Scale (GDS). Generalized estimating equations were used to model the longitudinal relationship between IL-6, sTNF-αR1, and GDS score. Whether lower extremity function, as measured according to the Lower Extremity Gain Scale (LEGS), explained the relationship between IL-6, sTNF-αR1, and GDS score was also examined. RESULTS: Participants in the highest categories of IL-6 (≥5.14 pg/mL) and sTNF-αR1 (≥2,421 pg/mL) had the highest GDS scores in the year after fracture (P = .09 for both). Twelve months after fracture, those in the highest IL-6 and sTNF-αR1 categories had GDS scores that were on average 1.9 (95% confidence interval (CI) = 0.4-3.4, P = .01) and 1.4 (95% CI = -0.1-3.0, P = .07) points higher than those in the lowest category, respectively. Adjusting for LEGS score, the mean difference in GDS scores for highest versus lowest IL-6 categories was 1.6 (95% CI = 0.2-3.0, P = .02) points at 12 months. CONCLUSION: Results from these exploratory analyses support a role for inflammation in the pathophysiology of depressive symptoms after hip fracture. Depressive symptoms in the context of high cytokine levels may represent a sickness syndrome that is chronic in some individuals. Further research should establish the cause and effect of this relationship, as well as long-term correlates.

Pressure-redistributing support surface use and pressure ulcer incidence in elderly hip fracture patients.

OBJECTIVES: To evaluate the association between pressure-redistributing support surface (PRSS) use and incident pressure ulcers in older adults with hip fracture. DESIGN: Secondary analysis of data from prospective cohort with assessments performed as soon as possible after hospital admission and on alternating days for 21 days. SETTING: Nine hospitals in the Baltimore Hip Studies network and 105 postacute facilities to which participants were discharged. PARTICIPANTS: Six hundred fifty-eight people aged 65 and older who underwent surgery for hip fracture. MEASUREMENTS: Full-body examination for pressure ulcers; bedbound status; and PRSS use, recorded as none, powered (alternating pressure mattresses, low-air-loss mattresses, and alternating pressure overlays), or nonpowered (high-density foam, static air, or gel-filled mattresses or pressure-redistributing overlays except for alternating pressure overlays). RESULTS: Incident pressure ulcers (IPUs), Stage 2 or higher, were observed at 4.2% (195/4,638) of visits after no PRSS use, 4.5% (28/623) of visits after powered PRSS use, and 3.6% (54/1,496) of visits after nonpowered PRSS use. The rate of IPU per person-day of follow-up did not differ significantly between participants using powered PRSSs and those not using PRSSs. The rate also did not differ significantly between participants using nonpowered PRSSs and those not using PRSSs, except in the subset of bedbound participants (incidence rate ratio=0.3, 95% confidence interval=0.1-0.7). CONCLUSION: PRSS use was not associated with a lower IPU rate. Clinical guidelines may need revision for the limited effect of PRSS use, and it may be appropriate to target PRSS use to bedbound patients at risk of pressure ulcers.

Delivery and outcomes of a yearlong home exercise program after hip fracture: a randomized controlled trial.

BACKGROUND: Hip fracture affects more than 1.6 million persons worldwide and causes substantial changes in body composition, function, and strength. Usual care (UC) has not successfully restored function to most patients, and prior research has not identified an effective restorative program. Our objective was to determine whether a yearlong home-based exercise program initiated following UC could be administered to older patients with hip fracture and improve outcomes. METHODS: A randomized controlled trial of 180 community dwelling female patients with hip fracture, 65 years and older, randomly assigned to intervention (n = 91) or UC (n = 89). Patients were recruited within 15 days of fracture from 3 Baltimore-area hospitals from November 1998 through September 2004. Follow-up assessments were conducted at 2, 6, and 12 months after fracture. The Exercise Plus Program was administered by exercise trainers that included supervised and independently performed aerobic and resistive exercises with increasing intensity. Main outcome measures included bone mineral density of the contralateral femoral neck. Other outcomes included time spent and kilocalories expended in physical activity using the Yale Physical Activity Scale, muscle mass and strength, fat mass, activities of daily living, and physical and psychosocial functioning. The effect of intervention for each outcome was estimated by the difference in outcome trajectories 2 to 12 months after fracture. RESULTS: More than 80% of participants received trainer visits, with the majority receiving more than 3 quarters (79%) of protocol visits. The intervention group reported more time spent in exercise activity during follow-up (P < .05). Overall, small effect sizes of 0 to 0.2 standard deviations were seen for bone mineral density measures, and no significant patterns of time-specific between-group differences were observed for the remaining outcome measures. CONCLUSION: Patients with hip fracture who participate in a yearlong, in-home exercise program will increase activity level compared with those in UC; however, no significant changes in other targeted outcomes were detected. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00390741.

Frequent manual repositioning and incidence of pressure ulcers among bed-bound elderly hip fracture patients.

Frequent manual repositioning is an established part of pressure ulcer prevention, but there is little evidence for its effectiveness. This study examined the association between repositioning and pressure ulcer incidence among bed-bound elderly hip fracture patients, using data from a 2004-2007 cohort study in nine Maryland and Pennsylvania hospitals. Eligible patients (n=269) were age ≥ 65 years, underwent hip fracture surgery, and were bed-bound at index study visits (during the first 5 days of hospitalization). Information about repositioning on the days of index visits was collected from patient charts; study nurses assessed presence of stage 2+ pressure ulcers 2 days later. The association between frequent manual repositioning and pressure ulcer incidence was estimated, adjusting for pressure ulcer risk factors using generalized estimating equations and weighted estimating equations. Patients were frequently repositioned (at least every 2 hours) on only 53% (187/354) of index visit days. New pressure ulcers developed at 12% of visits following frequent repositioning vs. 10% following less frequent repositioning; the incidence rate of pressure ulcers per person-day did not differ between the two groups (incidence rate ratio 1.1, 95% confidence interval 0.5-2.4). No association was found between frequent repositioning of bed-bound patients and lower pressure ulcer incidence, calling into question the allocation of resources for repositioning.

Repeat falls and the recovery of social participation in the year post-hip fracture.

BACKGROUND: although the majority of hip fractures are the result of a fall, whether repeated falls in the year post-fracture adversely influence recovery of social participation is not known. DESIGN: analysis of data from a longitudinal cohort study. SUBJECTS: community-dwelling women aged > or = 65 years, admitted to one of two hospitals in Baltimore with a new, non-pathological fracture of the proximal femur between 1992 and 1995. METHODS: information on falls was collected from a falls diary. At the baseline, 6- and 12-month evaluations, subjects were asked about the number of times in the 2 weeks prior to the evaluation they had participated in 10 categories of social activities. We examined the association of repeated falls with social participation using generalized estimating equations. The effect of physical and psychological functions was examined by including measures of lower extremity functional performance and depressive symptoms into the model. RESULTS: the analyses included 196 women, mean age = 80.2 years. Eighty-one subjects fell. The subjects with >1 fall between evaluations participated in a mean (95% CI) of 3.5 (0.12, 6.9) and 4.3 (0.9, 7.7) fewer social activities at 6 and 12 months post-fracture, respectively, compared to those who did not fall (P = 0.0003). These results were attenuated by adjustment for depressive symptoms, but not by lower extremity functional performance. CONCLUSIONS: in the year post-fracture, repeated falls in women were associated with decreased social participation independent of lower extremity function. Depressive symptoms in repeated fallers may partly explain this association.

Pressure ulcers in elderly patients with hip fracture across the continuum of care.

OBJECTIVES: To identify care settings associated with greater pressure ulcer risk in elderly patients with hip fracture in the postfracture period. DESIGN: Prospective cohort study. SETTING: Nine hospitals that participate in the Baltimore Hip Studies network and 105 postacute facilities to which patients from these hospitals were discharged. PARTICIPANTS: Hip fracture patients aged 65 and older who underwent surgery for hip fracture. MEASUREMENTS: A full-body skin examination was conducted at baseline (as soon as possible after hospital admission) and repeated on alternating days for 21 days. Patients were deemed to have an acquired pressure ulcer (APU) if they developed one or more new stage 2 or higher pressure ulcers after hospital admission. RESULTS: In 658 study participants, the APU cumulative incidence at 32 days after initial hospital admission was 36.1% (standard error 2.5%). The adjusted APU incidence rate was highest during the initial acute hospital stay (relative risk (RR)=2.2, 95% confidence interval (CI)=1.3-3.7) and during re-admission to the acute hospital (RR=2.2, 95% CI=1.1-4.2). The relative risks in rehabilitation and nursing home settings were 1.4 (95% CI=0.8-2.3) and 1.3 (95% CI=0.8-2.1), respectively. CONCLUSION: Approximately one-third of hip fracture patients developed an APU during the study period. The rate was highest in the acute setting, a finding that is significant in light of Medicare's policy of not reimbursing hospitals for the treatment of hospital-APUs. Hip fracture patients constitute an important group to target for pressure ulcer prevention in hospitals.

The association of race, gender, and comorbidity with mortality and function after hip fracture.

BACKGROUND: Few studies of hip fracture have large enough samples of men, minorities, and persons with specific comorbidities to examine differences in their mortality and functional outcomes. To address this problem, we combined three cohorts of hip fracture patients to produce a sample of 2692 patients followed for 6 months. METHOD: Data on mortality, mobility, and other activities of daily living (ADLs) were available from all three cohorts. We used multiple regression to examine the association of race, gender, and comorbidity with 6-month survival and function, controlling for prefracture mobility and ADLs, age, fracture type, cohort, and admission year. RESULTS: The mortality rate at 6 months was 12%: 9% for women and 19% for men. Whites and women were more likely than were nonwhites and men to survive to 6 months, after adjusting for age, comorbidities, and prefracture mobility and function. Whites were more likely than were nonwhites to walk independently or with help at 6 months compared to not walking, after adjusting for age, comorbidities, and prefracture mobility and function. Dementia had a negative impact on survival, mobility, and ADLs at 6 months. The odds of survival to 6 months were significantly lower for people with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and/or cancer. Parkinson's disease and stroke had negative impacts on mobility and ADLs, respectively, among survivors at 6 months. CONCLUSIONS: The finding of higher mortality and worse mobility for nonwhite patients with hip fractures highlights the need for more research on race/ethnicity disparities in hip fracture care.

Association between interleukin-6 and lower extremity function after hip fracture--the role of muscle mass and strength.

OBJECTIVES: To examine whether an effect on muscle mass or strength explains the association between interleukin-6 (IL-6) and lower extremity function in the year after hip fracture. DESIGN: Analysis of data from a longitudinal cohort study. SETTING: Two Baltimore-area hospitals. PARTICIPANTS: Community-dwelling women aged 65 and older admitted to one of two hospitals in Baltimore with a new, nonpathological fracture of the proximal femur between 1992 and 1995. MEASUREMENTS: At 2, 6, and 12 months postfracture, serum IL-6, appendicular lean muscle mass (aLM), and grip strength were measured, and the Lower Extremity Gain Scale (LEGS), a summary measure of performance of nine lower extremity tasks was calculated. Generalized estimating equations were used to model the longitudinal relationship between IL-6 tertile and LEGS. Whether muscle mass or strength explained the relationship between IL-6 and LEGS was examined by adding measures of aLM, grip strength, or both into the model. RESULTS: Subjects in the lowest IL-6 group performed better on the LEGS than those in the highest tertile by 4.51 (95% confidence interval (CI)=1.50-7.52) points at 12 months postfracture. Adjusting for aLM and grip strength, this difference was 4.28 points (95% CI=1.14-7.43) and 3.81 points (95% CI=0.63-7.00), respectively. Adjusting for both aLM and grip strength, the mean difference in LEGS score was 3.88 points (95% CI=0.63-7.13). CONCLUSION: In older women, after hip fracture, reduced muscle strength, rather than reduced muscle mass, better explains the poorer recovery of lower extremity function observed with higher levels of the inflammatory marker IL-6.

Amount of social contact and hip fracture mortality.

OBJECTIVES: To study the association between amount of social contact and mortality after hip fracture in elderly participants. DESIGN: Prospective cohort. SETTING: Community residents of Baltimore, Maryland. PARTICIPANTS: Six hundred seventy-four elderly participants. MEASUREMENTS: Amount of telephone and direct personal contact between participants and their relatives and friends and mortality up to 2 years after fracture. RESULTS: No social contact with friends during the 2 weeks before the fracture was associated with a five times greater risk of death over 2 years than daily contact with friends during the 2 weeks before the fracture (hazard ratio (HR)=5.04, 95% confidence interval (CI)=2.75-9.23). Participants with less than daily contact were also at greater risk of dying, although the CI spanned 1 (HR=1.76, 95% CI=0.99-3.13). Participants who had no contact with family members prefracture were more than twice as likely to die as those who communicated daily during the 2 weeks before fracture (HR=2.26, 95% CI=1.36-3.77). Participants who had less than daily contact were also more than twice as likely to die (HR=2.55, 95% CI=1.65-3.94). CONCLUSION: This study suggests that lower social contact before hip fracture is associated with poorer survival after 2 years.

Heterogeneity in hip fracture patients: age, functional status, and comorbidity.

OBJECTIVES: To examine unidentified heterogeneity in hip fracture patients that may predict variation in functional outcomes. DESIGN: Observational, longitudinal, multisite cohort study. SETTING: Three separate cohorts from five hospitals in the metropolitan New York area and eight hospitals in Baltimore. PARTICIPANTS: Two thousand six hundred ninety-two hip fracture patients treated at one of 13 hospitals and followed for 6 months postfracture. MEASUREMENTS: A mobility measure with three categories (independent (walks independently or with a device), limited independence (needs human assistance or supervision to walk 150 feet or one block or able only to walk indoors), and unable to walk) was developed for use with all three cohorts. A similar measure was developed for the other activities of daily living (ADLs): bathing, dressing, feeding, and using the toilet. Cluster analysis was used to form homogenous groups of patients based on baseline demographic characteristics, comorbid conditions, and baseline mobility and ADL independence. RESULTS: Seven homogeneous subgroups were identified based on prefracture age, health, and functional status, with measurably different 6-month functional outcomes. At least 90% of patients could be correctly classified into the seven groups using simple decision rules about age, ADLs, and dementia status at baseline. Dementia was the only comorbid condition that segmented the groups. CONCLUSION: The heterogeneous hip fracture population can be grouped into homogenous patient clusters based on prefracture characteristics. Differentially targeting services and interventions to these subgroups may improve functional status outcomes.

Association of serum vitamin D levels with inflammatory response following hip fracture: the Baltimore Hip Studies.

BACKGROUND: Vitamin D, known for its role in calcium homeostasis, may also regulate immune function. Whether vitamin D deficiency at the time of hip fracture is associated with the inflammatory response postfracture is not known. METHODS: In a cohort from the Baltimore Hip Studies, women aged >or= 65 years were evaluated at baseline and 2, 6, and 12 months after hip fracture repair. Serum at baseline was analyzed for 25-hydroxyvitamin D [25(OH)D], and serum from all time points was analyzed for interleukin-6 (IL-6). Participants were divided into two groups based on their baseline 25(OH)D levels. Vitamin D deficiency was defined as a 25(OH)D level of

Persistent changes in interleukin-6 and lower extremity function following hip fracture.

BACKGROUND: A hip fracture often heralds a period of functional decline in elderly persons. Although an inflammatory reaction would be expected following a hip fracture, whether the degree of this response is associated with adverse functional outcomes is unknown. METHODS: In a cohort from the Baltimore Hip Studies, women aged 65 years or older with a hip fracture were evaluated at 3 or 10 days (baseline) and 2, 6, and 12 months (follow-up) postfracture. Serum was analyzed for interleukin-6 (IL-6) level. A score of timed performance of 9 tasks, the Lower Extremity Gain Scale (LEGS) was calculated at each evaluation. We divided participants into tertiles based on their cytokine levels at 2, 6, and 12 months, and examined the LEGS score trajectories as a function of IL-6 tertile using generalized estimating equations, adjusting for age, prefracture function, body fat, pain, cognitive function, type of surgical repair, the number of in-hospital complications, and the number of comorbid medical conditions. RESULTS: At baseline, 2, 6, and 12 months, respectively, 149, 95, 101, and 82 participants provided serum samples; of these participants 65, 78, and 59 also provided a LEGS measure at 2, 6, and 12 months, respectively. At 12 months postfracture the median (interquartile range) of serum IL-6 levels was 7.4 (4.0, 15.9) pg/mL. Participants in the lowest tertile of IL-6 level performed better on the LEGS than did those in the highest tertile (p =.008). At 12 months postfracture, participants in the lowest tertile scored 5.3 points better (95% confidence interval, 2.0-8.6) on the LEGS than did those in the highest tertile (p =.002). CONCLUSIONS: Higher IL-6 levels are adversely associated with recovery of lower extremity function after hip fracture. Factors that predict cytokine response and the potential mechanisms by which this effect is mediated warrant further study.

Elderly patients with hip fracture with positive affect have better functional recovery over 2 years.

OBJECTIVES: To evaluate whether patients with hip fracture with high positive affect had better functioning than those with low positive affect or depressive symptoms in three performance-based measures over 2 years after the fracture. DESIGN: Longitudinal study with assessments at baseline and 2, 6, 12, 18, and 24 months posthospitalization. SETTING: Community. PARTICIPANTS: Four hundred thirty-two patients, aged 65 and older, hospitalized for hip fracture in Baltimore, Maryland, between 1990 and 1991. MEASUREMENTS: High and low positive affect and depressive symptoms were based on baseline Center for Epidemiologic Studies Depression Scale score, usual and rapid walking speed, one chair stand, demographic factors, comorbidities, and history of cognitive impairment. RESULTS: At each follow-up point, respondents with high positive affect at baseline (36% of sample) had faster walking and chair stand speeds than those with low positive affect (13%) and depressive symptoms (51%). For example, at 6 months, the mean usual walking pace was 0.4 m/s (standard error (SE)=0.02) for respondents with high positive affect, versus 0.4 m/s (SE=0.03) and 0.35 m/s (SE=0.02) for patients with low positive affect and depressive symptoms, respectively; adjusted differences were 0.02 (95% confidence interval (CI)=-0.06-0.09) and 0.06 (95% CI=0.01-0.11). Respondents with high positive affect appeared to achieve their maximum improvement in usual pace approximately 6 months before other respondents, but this interaction was not statistically significant. Respondents with consistently high positive affect had the best functioning over the follow-up period. CONCLUSION: High positive affect seems to have a beneficial influence on performance-based functioning after hip fracture.

Gender differences in functioning after hip fracture.

BACKGROUND: Hip fracture is a significant health problem for men and women; between 25 and 30 percent of all hip fractures are sustained by men. Relatively little is known about gender differences in functional outcomes after hip fracture. The purpose of the current study is to compare post-hip fracture functional recovery of men and women. METHODS: A sample of 674 patients age 65 or older were recruited as part of the Baltimore Hip Studies and were followed longitudinally for 1 year following fracture. Information on prefracture status and hospital course of treatment was collected as well as functional data at baseline, 2, 6, and 12 months postfracture. Data were analyzed longitudinally using Generalized Estimating Equations (GEEs). RESULTS: Men in the study were generally younger and suffered greater comorbidity at time of fracture. Men further suffered higher mortality in the year following fracture. Among survivors, little difference between men and women was seen in patterns of recovery of function following fracture. CONCLUSIONS: Hip fracture is not a problem affecting just women. Recovery following fracture for men is probably no better than that for women, even after mortality differentially eliminates the frailest male participants. However, psychosocial factors, greater comorbidity, and higher rates of certain complications among men may require adjustments to interventions designed to restore function. Further research into the consequences of hip fracture for men and women is needed.

The Lower Extremity Gain Scale: a performance-based measure to assess recovery after hip fracture.

OBJECTIVE: To develop and determine the reliability and validity of a sensitive observational measure to assess recovery in clinically meaningful areas of function after hip fracture. DESIGN: Used survey data to identify activities difficult to perform after fracture; conducted focus groups; interviewed patients; and developed a standardized protocol to prospectively test the highest ranking activities. SETTING: Evaluations conducted in 8 Baltimore hospitals or the patients' residence. PARTICIPANTS: Patients 2 to 24 months postfracture, 65 years and older, and community-dwelling. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The Lower Extremity Gain Scale (LEGS). RESULTS: Nine performance-based activities were appropriate for administration in clinical and research settings: (1) walk 3m (10ft); put on a (2) sock and (3) shoe on the fractured side; (4) rise from an armless chair; step (5) up and (6) down 4 stairs; get (7) on and (8) off the toilet; and (9) reach for an item on the ground from a sitting position. Reproducibility is good and measures of internal consistency and content, concurrent, and construct validity are high. CONCLUSIONS: The LEGS can be easily administered by clinicians in a short time as part of care. Research and clinical scoring methods and performance norms can track recovery in activities that are most relevant in the lives of patients.